PDP- Personal Dietitans Perspective

Jan Biggart Community Team Lead

GCWMS19.11.13

PDP

Role • Team Lead• Community Co-ordinator• Dietitian – the programme and a recent

group presentation / the patients journey.

“The programme”

• Phase 1• Delivered by Specialist Obesity Dietitians • 9 x 1.5 hrs x fortnightly• 3 components

–Diet, Activity, Behaviour

Session 1

• Causes of Obesity• Program Overview• Benefits and Costs• Looking Ahead• Benefits of 5-10kg weight loss• Goal setting• Eat Well Plate• Becoming More Active• Lifestyle Diaries

Session 2 – Taking Control

• Personalised Dietary Prescription

• Barriers and benefits to becoming more active

• Setting goals and taking control

Personalised Dietary Prescriptionof 1500 calories per day

Food group Portions recommended per day

Starches (bread, cereals, potatoes, rice, pasta)

6

Fruit and Vegetables 6

Dairy 3

Meat, Fish, Alternatives 2

Fats (butter, low fat spread, oil, mayonnaise, salad cream)

2

Extras (sweet foods, extra portions, dessert, alcohol, crisps)

130calories

Session 3 – Planning For Success

• Menu planning, shopping and guide to food labelling

• Binge eating

• Introduction to Activity

Session 4 – Changing Habits

• Cooking and eating out/take a ways • Changing habits

• Dealing with social pressures to eat

• What you can do to fit in physical activity

• Pedometers

Session 5 – Go Do It

• Unhelpful Thinking – Thoughts, Feelings and Behaviour

• Physical activity - what's available

• Diet Quiz

Session 6 – Riding The Craving Wave

• Cravings vs. Hunger

• Practical Dietary Tips

• Physical activity quiz

Session 7 – Keep It Real

• Diet Myths/Fad Diets & the Balance of Good Health

• Staying Motivated to be Active

• Body Image

Session 8 – The Journey So Far

• What diet changes have been made?

• What activity changes have been made?

• Relapse prevention

• High risk situations

• Setbacks

• Support

Session 9 - Review

What is Next…..• Mini Eating Questionnaire/ Self Help Manual• Lost 5kg options• Not Lost 5kg options

– Low Calorie Diet (1200kcals/1500kcals)– Pharmacotherapy (Orlistat )

Enter Phase 2 (3-6months) then Phase 3 (12months)

Phase 2 / Phase 2b

• 4 x monthly sessions of FWL (3 months) with :

• Pharmacotherapy ( Orlistat )

or• Structured LCD 1200 – 1500 kcals ( with

meal replacements )

Phase 3- Maintenance

• Evidence : is less abundant• Varying descriptions of success • Will expect some weight regain• SIGN guidelines• GCWMS : unpublished data / pilot• NWCR : www.nwcr.ws• Our aim is to maintain the 5kg loss target for 12 months.• Attending the P3 maintenance programme significantly

improves outcomes.• Continue to develop and review.

Preliminary findingsMaintenance

Study :18 month follow up assessing weight maintenance of successful weight loss patients

• 50% of patients maintained > 5kg weight loss

• 87% of patients weighed less than initial weight at follow up

• Attending maintenance programme was highly significant in successful maintainers

Phase 3- Maintenance

Most successful strategies to maintenance:• Following a low fat/ high carbohydrate diet• 1 hour moderate intensity activity/ day• Regular eating including breakfast• Self monitoring through lifestyle diaries and

weekly weight checks.• Maintaining a consistent eating pattern across

weekdays, weekends and holidays.• Monitoring changes in mood.

Group Presentation - Stobhill Evening Group

Looking at data for 19 months ( for research purposes look at 1 year )

Stobhill Evening Group - Phase 1

• 11 started • 4 males : 7 females • 8 Completed ( 73% )• 5/8 ( 62% ) Success weight loss > 5kg

( Range 6.1kg to 13kg )

Stobhill Evening Group – Phase 2 (i.e. 7 month data)

• 8 patients started • 5 completed ( 45% ) 4 males and 1 female • 5/8 (62%) a success after phase 2

SEG – End Phase 3, Maintenance(i.e.19 month data)

• 5 patients started• 4 completed (80%) 3 males and 1 female

( 36% of programme starters) finished the programme.

• 1. A• 2. G• 3. C• 4. T

Look Beyond the Weights

• Look at anecdotal evidence• Look at patient feedback forms• Look at QOL / Psychology reports• Look at improved biochemistry• Look at physical activity

Results at end of programme

Weight/ Ax wt P1S1 P1S9 Wt loss P1 / % wt loss

P3S11 P1S1 to P3S11

  Total wt loss / % wt loss

Patient  

1. A 127.4 119.4 109.9 9.5kg / 7.9% 104.9 14.5kg / 12.1%

2. G 119.8 111.1 105 6.1kg / 5.5% 102.4 8.7kg / 7.8%

3. C 112 108.6 101.7 6.9kg / 6.4% 88.1 20.5kg / 18.9%

4. T 118.5 119.3 113.7 5.6kg / 4.7% 96.7 22.6kg / 18.9%

Results – BMI (kg/m2)

BMI at referral BMI at end of programme

1.A 44 40

2.G 38.7 33.1

3.C 37.7 29.4

4.T 35.9 29.7

Weight loss journey

0

20

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60

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140

1 2 3 4

Phase of Programme

Wei

gh

t (k

gs) Ax wt

P1S1

P1S9

P3S11

Individual Patient 1

• 51 year old female, total weight loss since ax 22.5kg• Has adult asthma and arthritis• Dietary changes : has reduced portion sizes and total fat

intake.• Activity changes : initially had not done any activity for 6

years. Now walks dog regularly and attends gym 3 times a week.

• Behaviour : “I had the knowledge but I've learned new skills, particularly around lapses and in the group I felt supported and not judged”.

• Benefits : “The support of this service and the classes in particular has helped me to lose a lot of weight and improve my general health”

• Previously used inhaler every morning, got breathless on stairs and now rarely uses inhaler and runs up stairs. Has less pain in left knee.

Individual Patient 2

• 65 year old gentleman, total weight loss since assessment = 17.4kg

• Has Bronchiectasis, stopped smoking 8 yrs ago and weight increased. At ax “wanted to improve breathing”

• Dietary changes : “changed eating habits completely”. Reduced portions fat and sugar. Increased fruit and veg.

• Activity changes : previously had to stop walking after < 1 mile, now walks 4 miles and uses an exercise bike regularly.

• Behaviour : kept a diary initially.• Benefits : reduction HbA1c (March 2011 was 45 and

2.11.12 was 39), reduced breathlessness, increased general fitness.

Individual Patient 3

• 44 year old gentleman, total weight loss since ax = 23.9kg

• Had MI 2009, has LVF and pace maker insitu. At Ax I wrote “ not sure of programme, just wants a diet sheet”.

• Dietary changes : Previously had a lot of take aways and convenience foods. Reduced these and portion sizes.

• Activity changes : Now attends gym 3 x / wk and walks for 45 mins x 4 / wk

• Behaviour : group helped develop problem solving skills. “has changed his habits, is a bit of a robot”

• Benefits : Improved heart health, improved sleep, less breathless, feels brighter and more alert. Has changed his girlfriends and daughters lifestyle.

• Ref : Cardiologists letter - Diagnosis : “previous obesity”

Individual Patient – 4.

• 34 year old gentleman, total weight loss since ax = 21.8kg

• No significant medical history, is a chef in a care home.• Dietary changes : Has reduced portion sizes, reduced

chocolate, crisps and chips. Adapted cooking methods, and increased fruit and vegetables.

• Activity changes : previously did no activity and now attends gym x 3 / wk and walks 4 miles x 6 / wk.

• Behaviour : has changed habits, kept a diary at the beginning

• Benefits : feels fitter, breathing better.

MDT working !